Purpose:
Based on the US Center for Disease Control Guidelines, service providers, daily, are encouraged to screen all clients for signs of respiratory illness accompanied by fever.

Instructions:
All clients being treated by Natalie Sharp, NP must be asked the following questions below. Natalie Sharp, NP of Applied Aesthetic will maintain this record for 14 days from completion of this form and have this form available upon request from the Public Health Department.

  • If YES to any, please call and cancel your appointment immediately.

    If you've answered NO to all, proceed to remain statements.
    If you answered NO to all questions you will be allowed entry to the building. Please be aware of the following protocols:

    - Your temperature will be taken at the beginning of your appointment.
    - You will immediately wash your hands for at least 20 seconds upon entry into the office.
    - Not to shake hands with, touch, or hug others during your time in the office
    - Not congregate in any space within the office.

    If this is in your residence, Natalie Sharp, NP will come in, take your temperature.M/strong>
    - She will wash her hands upon entering.
    - She will have her mask and gloves on for the duration of your appointment.

    By signing the form below I am acknowledging the potential risk to contract the COVID-19 disease during services provided today and voluntarily agreed to accept services. You further agree and hereby release Applied Aesthetic & Natalie Sharp, NP from any and all liability associated with your potential risk to contract NOVEL CORONAVIRUS (COVID-19).

    The person answering YES to any of the above questions is responsible for following-up with their primary care physician if needed.

  • Date Format: MM slash DD slash YYYY
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